STEMI (ST-Elevation Myocardial Infarction)

Dispatch: 8:07 Chest Pain
Enroute: 8:08
On Scene: 8:14
At Patient: 8:15

66-year-old female with 3 out of 10 chest pain X 2 hours. Periodic chest pain for last week. Skin warm and dry. No prior heart hx.

Initial 3-lead strip: 8:16



Vitals, 02 by cannula. 324 ASA PO. Patient shirt removed, put in hospital gown

Initial 12-Lead: 8:19 (Watch V4 in particular, as well as V1-V3 over course of ECGs)



IV # 18 in left AC. 0.4 NTG SL

Depart Scene: 8:21

Hospital called for official STEMI Notification: 8:22

2nd 12-lead ECG: 8:22 (Note LP12 spitting out 12-leads every three minutes.



8:23 2nd NTG SL. 2nd IV # 18 in right AC

(In meantime hospital alerting cath lab team)

8:25 3rd 12-Lead ECG



8:26 Cath Lab team arrives in ED

8:28: 4th 12-Lead ECG Pain now up to a 5.



Begin preparing patient for quick exit from ambulance

8:31 5th 12-Lead ECG



8:34 Out at Hospital

8:35 Transfer Care to ED Doc/medical staff/ cath lab team

8:36 Hospital ECG



Next ten minutes Patient is prepped(additional drugs, procedure discussed, consent given) and then hustled upstairs.

8:50 Patient hits cath lab table.

9:08 Balloon inflated (Hospital Door to Balloon Time - 34 minutes).

Patient has 100% occlusion of Left Anterior Descending artery (The Widowmaker). Suffers arrhythmia. V-Tac. cardio-verted X 1. Then full reperfusion.

Normalized ECG.

***

First there were hospitals, then ambulances, then emergency departments, then EMTs, then paramedics, then prehospital ECGs, and then STEMI alerts with cath lab notifications.

Progress

***

Paramedics Activate Cath Lab for STEMI Patients in Some Areas

Cardiac Arrest Thoughts

I've been doing this a long time -- 15 years as a medic -- and it amazes me how often I find new ways to do things or think about things.

I did another cardiac arrest yesterday. Fairly routine. Yet another nursing home hospital bed one legged diabetic dialysis patient pulseless, apneic, CPR in progress, first responders defib - No shock advised. Patient a full code. Done it many times before, so what was different?

1. My eyesight is getting worse. I've remarked on it before how I have to squint sometimes when I am trying to thread a 24 gauge catheter into a tiny vein. Yesterday I had trouble reading the lip line markers on the ET tube. The lighting wasn't great and there was some thick mucus on the tube, but I couldn't tell if the number at lip line was 21 or 23? I couldn't make it out. I squinted harder, but still couldn't see it clearly.

Also when the nurse handed me the W10, I was trying to read the medical history and again, I couldn't read it. It is one thing to sit on an ambulance bench seat on a nice easy ride to the hospital and read a W10, but in the middle of a code when you are the only ALS provider, it is quite another. I have decided in the future what I will do is have the nurse stand by me while I am doing my code things and read the W10 aloud. Start with medical history and proceed through the medications. I have of necessity over the years learned to make use of nursing home staff on codes -- yesterday they did a fine job with CPR and handing me what I asked for from my gear, that this is just a logical extension.

2. ETCO2 and cardiac arrest. I have also written about this extensively (See Post), but I continue to gain new insights. The clear utility of continuous capnography is a quick verification that your tube is good (you still have to listen to lung sounds because ETCO2 won't detect a right mainstem). The other benefit is it can provide a glimpse into your patient's survivability chances as well as measure how well CPR is being done. This woman had an ETC02 of 35 on intubation (with CPR), which suggested she was not as dead as she looked. She was initially in a PEA but after some epi went into v-fib. I shocked her a total of three times, then she went back to a PEA, which dwindled to asystole and then back and forth between PEA and asystole for the duration of the call. I don't like to transport dead people, so I usually follow the 20 minute and out rule for patients in asystole, and under our new guidelines I can call medical control to cease resuscitation even on patients who have been in v-fib or PEA for a period of time if after 20 minutes, they remain pulseless. The problem here was we were getting such good ETCO2 readings. The patient stayed in the 20-30 range. What was most interesting was every time I gave her epi, the ETCO2 rose up to the 30's. We never did get pulses back. My guess was a dopler would have showed a BP in the 50's or 60's during the epi effect. Anyway, I felt we had to bring her in.

Now in the past without ETCO2 to monitor the effectiveness of CPR many of us became rather casual in our efforts. The patient was dead and wasn't coming back but was still alive enough that we had to work them. Now with ETCO2 measuring the effectiveness -- basically, the better your CPR, the better the cardiac output, the higher the ETCO2 number -- you are obligated to maintain maximum CPR efforts. As soon as you start to get lax, the monitor is going to tell you. 28, 27, 26, 25, better start pumping harder. 26, 27, 28. You stop CPR briefly to switch positions or administer a drug and your ETC02 is down to 18, 17, 16, 14. And it takes some pumping to get it back up into the mid 20's.

I had just one partner yesterday so he drove, while a cop rode in the back with me, which leads to another thing I learned.

3. IOs -- I love the EZ-IO. One legged diabetic, dialysis patient with me the only ALS responder, it's a no brainer -- I don't even look for a peripheral vein, I just get out the drill. Brrrrrr. I have access in the tibia. But here's the problem. In the past, I would have put in a line in the AC or an EJ, which would enable me to sit at the head and bag the patient while also administering drugs. I could do a code with just two people in the back. But now with the line just below the knee, no way. So, I'm trying to administer drugs and do CPR at the same time. That's challenging. You stop CPR for a moment and the ETCO2 plummets because your circulation/pressure has just dropped to Zero. Epi and atropine push pretty easy and quick, but due to the patient's history and down time, I decided to try some bicarb. Let me tell you bicarb is a bear to push through an IO. Its like pushing D50 through a 24. It is slow, so I'm doing one-handed CPR, and one handed bicarb pushing against the bristojet, all trying to maintain my balance as we go over the bumps in the road. Bottom line, I really need to get a third person in the back.

4. The patient's husband was in the nursing home lobby. When I saw him, I do as I often have done in the past -- have him come over and say something brief to his spouse. I do this to give them a chance to say goodbye. I tell them we are breathing for their spouse, but they may still be able to hear. And then the one says to the other, I love you, etc. I want them to have that moment, and it usually works out well. Yesterday, I did it, and the man told her heartfully he loved her and then we pushed on through the door and then behind us came an awful howling. A howling that did not abate. I could only picture the man on his knees crying out to the heavens.

It is hard to know what is right sometimes. Did I give him a chance to say goodbye? For him to know that his loved wife heard his words? Or did I give him an awful memory that he'll never forget -- a picture of his unresponsive wife on a board with a plastic tube sticking out of her mouth and people pounding on her chest?

They worked the patient in the ED for another twenty minutes. She had a recent admission for hyperkalemia so they gave more bicarb and then calcium, but to no avail.

Collar-Applying and Other Paramedic Skills

I was talking with a hospital management person the other day about how much I love being a street paramedic, and how I didn’t think I could do my new job – a part-time position as a clinical coordinator at the hospital if I wasn’t still working in the street. The manager’s response was I could do more good in my new position and that the manager never understood all the big deal about putting on a collar. Anyone could put on a cervical collar.

I’ve been thinking about the comment, and while the manager did have a point – good management people can affect a far greater array of patients than a single clinical practitioner – being an EMS responder is of course, about much more than putting on a collar, about much more than simple do again and again skills.

I had a call the other day that helped bring the question into focus. We were called to a local restaurant for a woman passed out in the bathroom. Not an unfamiliar call. Usually, a person with a bad case of diarrhea or vomiting. Sometimes a young woman having her period, who hasn’t been eating or drinking enough.

Then we were updated that it might be a cardiac arrest, and then another update – a likely diabetic.

So I go in, for better or worse, in diabetic mode. I have all my equipment (house bag, monitor, 02, stretcher), but I am thinking, check the sugar, it’ll be low, pop in an IV, push an amp of D50, try to persuade the patient to go to the hospital, but likely end up with a refusal. We’d watch the patient now alert, eat some food and then leave under the care of a friend. Done variations of it 100 times.

A morbidly obese woman is lying on her back in the middle of the bathroom – not in a stall. For all intents and purposes she is out cold. Her skin is warm and dry and her breathing has just a hint of the dreaded “guppy breathing.” I try to ignore that ominous sign. Already I am thinking this is probably not a diabetic, but maybe she is breathing this way because she is so fat and laying on her back is not helping her breathe any. I slap the nasal end-tidal on her and am relieved to see a reading of 30. While a partner tries to get a blood pressure -- I can't feel a pulse, but her wrists are fat -- my plan is do a quick sugar check. If it reads low, then we are all set, if it is normal or high, it’s on the stretcher and out to the ambulance lickety -split. 220. Let's get her out of here, I tell my crew. I'm now thinking maybe CVA. We roll her on board, lift her quickly and are on our way, ambu-bag in hand to assist ventilations if necessary and I am thinking it may soon be necessary.

In the ambulance, I intubate her quickly. No gag at all. Good tube. I can't make out the chords, but can see the epiglottis and lift it as high as I can. I have preattached my capnography filter and am confident I can slide the tube in. I pass it carefully. My fingertips feel a little resistance. I think I am at the chords and I push through. On the monitor, I see the beautiful ETCO2 wave form. I check lung sounds. Pefect. I secure the tube and then look back at the monitor - the ECG leads now attached. She is bradycardic in the 40’s and looks almost like she has a funky block. Is it from hypoxia or is this a cardiac event. I don’t see a hint of a vein, so without investigating further I get out the EZ-IO and drill, baby, drill. The only problem is her leg is so fat, I am already up to the hub of the catheter and it is spinning around and around in the gelatin of her skin, finding no purchase in bone. I take the needle out, find a new spot and bear down hard. This time I make it though to the bone, solid. I secure the IO, attach a bag of fluid, wrap a pressure dressing around it, and then push in a milligram of atropine. No change. A couple minutes later, I push a second milligram, and this time it does the trick. Her rate comes up to the 80’s. With a hundred ccs of fluid in and her heart cranking to boot, we finally get a blood pressure -- 100/60. Her end tidal is a perfect 40.

As we approach the hospital, I am feeling pretty good about my care, and I’ve got that old medic stud rush going on, but then when we get to the ED, the doctor asks for the story, and it occurs to me then I never really got a story beyond the dispatch. I was so caught up in the moment, I never did find out what happened. I knew nothing about the patient other than the fact she was a diabetic. I had no witnesses, no one who could tell me anything about her or what had happened, before, during and after. While I immobilized her on a spine-board, that was more to be able to lift her and manage her in the event she arrested than to protect her spine. I never considered the fact she might have been a trauma. As I sit to write my run form, and come to the boxes about pupils, I slap my forehead. Pupils? Do’oh. I never looked. Suddenly I wonder if maybe she was a heroin OD and could have been woken up with a touch of narcan before dismissing the idea as sudden paranoid fantasy. When I go to put down my drug doses, I realize I lapsed back to the old dosing scheme for atropine, not the latest ACLS guidelines, which call for a half milligram instead of the whole. My bad.

Later, after the family comes to the hospital, we get more of the story. The woman had started acting confused, and then went to the bathroom with an awkward gait, and then synocopized entering a stall, was helped to the ground, and then dragged out of the stall by her ankles. I’ve followed up a couple times, and she remains in the ICU. Her labs weren’t significantly off. Her CAT scan clean. They don’t seem to know what happened. A mystery.

But anyway, the point of this story is that what I like about EMS is the challenge – the array of skills you need to bring to a call -- assessment, scene management, intubation, pharmacology, and that no call, no matter how well you may think you are performing goes flawlessly. I did great in some areas and was weak in others. But it just goes to show how much is involved in a call. It is not just about putting a collar on. In this case particularly because I never got around to putting one on(if i could have found one to go around her ox-like neck), which certainly would have been indicated if I thought she was a trauma or merely indicated because it is good practice because I don't know it is not a trauma.

I no longer expect to be perfect. But I still relish the challenge. A situation is thrown at you and you have to perform. Sometimes you do great, sometimes you stumble, most of the time, you are somewhere in between. It is exciting. I am much better at it than when I first began, but always have room for improvement. You learn from each call, and although you never get the same call twice -- there are no direct do-overs -- you always get a chance to redeem and hopefully, shine. I took pride in my tube, but next time I will work to improve my history taking skills or delegation. I should have just said to one of my partners. Find out what happened for me. Be quick about it and report back. I love delegation. I need to use it more.

So anyway, after several days working the new desk job, I’m back on the street. Instead of reading other medics run forms and living vicariously through their exploits, I’m out there doing it, touching patients and writing my own run forms again. And it’s been busy today, only the calls are not really what I had been hoping for. No big tests yet.

Old lady with a heart history in a neck high bathrobe stone cold deaf having chest tightness with a congested cough. I like to get my patients in a Johnny, but disrobing her was just going to be too hard, plus it was pouring rain outside and we needed to stair chair her out and I didn't want her to freeze. In the ambulance, trying to do a 12 lead, and explain to a deaf lady why I needed to reach down her robe was challenging. Not as challenging as the lady in the restaurant, but a challenge nonetheless. Then it was two nursing home calls one for a woman with dementia and paranoia with a fever and coughing up green phlegm which she had all over her fingers, the other for a man with MRSA affected weeping wounds. That patient refused to get on our stretcher until he had put his good clothes on and gone to the bathroom. He was also close to four hundred pounds. And it was still pouring rain. The challenge on those calls was how many times and with what variety of soaps, sanitizers and disinfectants could I wash my hands.

The potential paramedic skill set is limitless.

Betrayed

My old partner Arthur once said I was too nice -- that I believed everything my patients told me. I didn't really agree with him. I was actually sort of torqued he said it because he told it to a newspaper reporter who was riding along with us that day to do a story. I didn't like the implication that I might be naive or gullible.

True, he made that comment ten years ago, but I think I am as good as anyone at sorting out the bullshit. I've done enough calls over the years to be have been able to build up a pretty good "Yeah, right" meter. I can spot a fake seizure the moment I walk in the door. I need a little more proximity to a patient to tell when they are feigning unresponsiveness, but I am rarely fooled. These of course involve a degree of physical assessment and observation. Any medic who has spent his time in the street can pick this up. After awhile, you run out of ways to get burned. You've learned every trick in the book, and you don't fall for the shit anymore.

I remember quite a number of years ago I was called to help another medic on a seizure call. This was when we only carried Valium and could only give it IV. A patient was seizing, you had to get a line and this medic was having trouble getting one. I opened up the back door and saw right away that the patient was arching their back and moving their limbs asynchronously. I climbed into the back leaned over the man and said "Knock it off!" he immediately stopped. I nodded to the other medic, who was dumbfounded. Then I exited, clearing the assist without another word.

I have found that phrase and the authoritative tone behind it to be quite effective on other similar occasions.

I don't mean to imply that I am never fooled. I am. But if I am fooled, it is because I have come to start taking the patient at their word, and I pass their word on with the phrase, "patient states..."

When I was a younger medic it was a badge of honor to never be fooled. For some reason it came to deal with your manhood. A stud medic was never fooled. It wasn't just a patient deliberately fooling you with their story, but fooling you with their presentation. That, for some (never for me), meant not treating a patient with pleuritic chest pain, not working up a drunk, not c-spining an elderly person with a low fall because you were sure they didn't have a fracture. And giving pain-meds to anyone, forget about it. You couldn't let a drug-seeker fool you.

Drug seekers do fool me. Not all of them, but I have been burned by a few just because I would rather give drugs to a drug-seeker than deny someone in legitimate pain.

I guess my basic attitude these days is, who am I to judge? I have to go with what people tell me. You look fine, but you tell me you are sick, okay, what hospital do you want to go to? I'll just relay what the patient (or bystanders) tell me, and then I relay what I have seen. Just the facts.

Still I am hurt when I find out someone has lied to me. Here's what happened the other day:

We get called for chest pain. Attractive 45-year-old woman at work having ten out of ten chest pain. Pain goes into her neck and down her arms. She's been having the pain for an hour, but she still drove to work. She is under a lot of stress. She's going through a divorce. There have been layoffs at work. Nice woman. She's been seeing a psychiatrist for anxiety. This she says feels like an anxiety attack, but much worse. Those have never lasted longer than five minutes. She's a little hypertensive (BP 170/100), a little tachycardic (104-112) skin warm and dry, has some congestion in her lungs, she says she's getting over bronchitis. She's all concerned she needs to call her mother and she doesn't want to worry her mother.

I put her on oxygen by cannula. The nurse at her job has already given her aspirin and one nitro with only temporary relief. I pop her on the monitor and the initial leads look good. NO ST elevations. I tell the nurse, we'll do the full workup out in the ambulance. The nurse notes a PVC. Maybe, I think or maybe it is just a wire being jostled.

I ask the patient for some more history. Anything different today or recently? Anything out of the ordinary? Any reason you could be feeling like this?

No. Just the stress. Lots of stress.

The patient is having an anxiety attack in my opinion, but I fully plan to treat it as cardiac. I explain this to her. I don't think it is your heart, I say, but I'm going to treat you like it is.

The full 12-lead is normal, except for a PVC or two. I ask her if she has ever had any heart trouble or the feeling of an irregular rate. She says no. I am seeing an occasional PVC -- unifocal, but fairly regular. So I guess it is more than an occasional PVC. That is a concern. I give her a full three nitros that don't seem to help, but do bring her pressure down a little. She is bouncing off the walls now with her anxiety, and I am seriously thinking about giving her some ativan. And, while I rarely give morphine to patients with chest pain (due to some recent literature that raises the possibility that it may do more harm than good), I go ahead and give her 2 mgs and then another 2 mgs just to calm her down.

It gets her pain down to a 6. Throughout all of this, she is complimenting me, telling me what a nice guy I am, how compassionate I must be to do this work. She keeps her arm on my knee. She calls me by my first name. Asks me if I am married? When I show her the pictures of my daughter, she tells me what a beautiful girl she is. I feel we are bonding. Not just paramedic to patient, but person to person.

We, of course, are well on our way in to the hospital. Not going lights or siren, but proceeding directly. I call in my patch that goes something like this:

"We're five minutes out with a 45 year old female with substernal chest pressure X 1 hour that goes into arms and neck. No prior cardiac history. Patient does have a history of anxiety and recent bronchitis. The 12 lead is normal, but the patient is having occasional PCS. She says she has had similar episodes in the past none lasting more than 5 minutes that her doctor's attribute to anxiety. She's gotten ASA, NTG X 3 and 4 of morphine with the pain initially a 10 of 10 now down to a 6..."

Pretty impartial patch. I'm basically saying she's having chest pain, but there is a good possibility it is anxiety. She'll need a room in the main with a cardiac workup, but there is no need to activate the cath lab yet or haul an ED doctor out of a procedure to prepare for our arrival. Just a room with a nurse and an ECG machine to start.

We get her registered, get her to the room. She is much calmer now. I get her to sign my run form. She thanks me again for being so nice. I go and find a nurse, who is very busy with another patient so I sit near the nurse's desk, typing up my run form until I can give her the report. She's finally ready and I bring her into the room and give her the run down while a paramedic student looks for an ECG machine. The nurse has some general questions for the patient and I excuse myself to head out for the ambulance. The patient calls after me, thanking me again. I say you are in good hands.

I come back later with another patient and when I see the nurse I ask how the woman made out. Was it anxiety or truly a cardiac issue?

Sky high cardiac enzymes, the nurse says. She's upstairs waiting for the cath lab.

Really?

Then the nurse says the patient finally admitted that she did some cocaine with her boyfriend late last night.

Cocaine.

I have to admit, I felt hurt. Betrayed. She shouldn't have hidden that from me. I thought we were friends.

A Dark and Stormy Night

Well, for the last month now we have been using electronic run forms. For the most part, I like them. I like most being able to type out an extended narrative, instead of trying to scribble it all into a confined space. (I know you could always attach a supplemental page, but I rarely did.) I like that people can read my writing now.

I've never considered myself a great run form writer. I would scrawl out a basic template that, if you could make out the chicken scratch, usually went something like this:

"76-year-old female not feeling well since last night. Denies chest pain or dsypnea. Vomited X-1. No diarrhea. Found supine in bed. GCS-15, skin warm dry, lungs clear, ab soft non-tender, good neuros. Vitals as below. Sinus, no ST aberrations. IV # 20 in Left forearm. S. Lock. BS-144. Taken to hospital, turned over to ED staff with full report."

But now with a keyboard and an unlimited space, I can be more free-flowing.

I did a call recently involving an old man found curled up in his apartment with altered mental status (See Sha La Lala Lala, Live For Today).

The next day I received an email from the hospital's Clinical Coordinator asking for a copy of the form for my stroke patient. I guessed he was talking about the old man found curled up in his apartment who was possibly a stroke patient. But I knew I had given a copy of my run form to the nurse as well as put a second copy in the QA box, which I told the Coordinator in a return email.

Still, I spent a sleepless night, wondering if I had done something wrong.

He emailed me back that the reason he was looking for the form was because the stroke doctor (the patient did have a head bleed) said it was one of the best run forms he had ever read.

I emailed him back asking if he was sure it was my patient and not one brought in by my relief later in the day. I said I did not think I wrote very good run forms and it was likely my relief who wrote excellent ones.

He emailed me back that it was indeed my patient, and that the doctor had been very impressed with the narrative that was full of information (scene description, co-worker's account, etc.) that had been very helpful to him.

The narrative. Yes! I had written quite a detailed narrative.

Suddenly I began to understand the meaning of it all.

I've written novels, essays, memoirs, speeches, poems, blog posts, and now I can write RUN FORMS!

Writers so love audiences. Might I say, we desperately crave them.

Now I have an entirely new audience.

Nurses, ED physicians, stroke doctors, cardiologists, trauma surgeons, internists, maybe even medical records personnel.

Now each time I sit down to do an electronic run form, after checking the obligatory boxes, my heart rises as I begin to type. I think I mustn't disappoint my readership. I must educate and entertain them. I must make them feel as if they were there on the call with me. Ahh, the poetry of it!

After a motor vehicle accident, I ponder a moment, and then inspiration strikes.

I type:

"It was a dark and stormy night..."